•Well-circumscribed, flat lesions that are
noticeable because of their change from normal
•They may be red due to the presence of
lesions or inflammation, or pigmented due to the
Presence of melanin, hemosiderin, and drugs.
Solid lesions raised above the skin
surface that are smaller than 1 cm in
diameter. Papules may be seen in a
wide variety of diseases including
erythema multiforme simplex, rubella,
lupus erythematosus, and sarcoidosis.
Solid raised lesions that are over 1
cm in diameter; they are large
These lesions are present deep in the
dermis,and the epidermis can be
easily moved over them.
Elevated blisters containing
clear fluid that are under 1 cm
Elevated blister like
lesions containing clear
fluid that are over 1 cm in
Moist red lesions often caused by the
rupture of vesicles or bullae as well as
A Non specific term used to describe any
abnormal area of the oral mucosa that on
clinical examination appears whiter than the
surrounding tissue and is usually slightly raised
,roughened or of a different texture from
adjacent normal tissue.
Any area of reddened mucosa that may be
smooth and atrophic looking or exhibits a
granular, velvety texture
Precancerous Lesions: defined as a morphologically
altered tissue in which cancer is more likely to occur.
Leukoplakia , Erythroplakia, Actinic chelitis, Palatal
Changes with Reverse smoking.
Precancerous condition: defined as a generalised state
associated With significantly increased risk of cancer.
Syphilis, OSMF, Siderophenic dysphagia, Erosive Lichen
White lesions classification
HEREDITARY WHITE LESIONS
REACTIVE INFLAMATORY WHITE LESIONS
INFECTIOUS WHITE LESIONS
IDIOPATHIC TRUE LEUKOPLAKIA
ORAL LICHEN PLANUS
DEVELOPMENTAL- ECTOPIC LYMPHOID TISSUE
GINGIVAL CYSTS OF ADULT N NEW BORN
WHITE SPONGY NEVUS
CHEMICAL INJURIES OF ORAL MUCOSA.
SMOKELESS TOBACCO INDUCED KERATOSIS.
SANGUINARIA INDUCED LEUKOPLAKIA
DEVELOPMENTAL WHITE LESIONS
—ECTOPIC LYMPHOID TISSUE
GINGIVAL CYSTS OF NEW BORN N
FITZ PATRICK et al-1993 defined Lichen
Planus as a unique cutaneous entity
consisting of an eruption of papules distinct
in color and configuration, in patterns and
location of appearance and in microscopic as
well as gross structure.
Unknown Antigen enters OMM
Antigen presentation by
langerhans cells of OMM
Increase in local cytokine production
Intense inflammatory reaction
Basal cell degeneration
Basal cell degeneration
Pyknotic and shrunken
Incapable of phagocytosis
Extruded into the
•Disease of middle aged,females and elderly
•Except for erosive and Bullous forms all other
forms are frequently painless and unrecognized by
•About 50 % of patients have skin lesions
violaceous hue and a fine scaly surface.
•Consists of slightly elevated,fine,whitish lines(wick
ham's striae)that produce either a lace like lesion or
a pattern of fine radiating lines(linear) or annular
•Lesions are bi-lateral
•Cheeks and tongue are commonly affected
•Papular,plaque,atrophic and erosive lesions are
frequently associated with reticular form.
PAPULAR AND PLAQUE TYPE
•0.5-1 mm whitish elevated areas or papules
are usually seen,plaque like lesions are also
seen that cannot be differentiated from
•Seen on keratinized and non-keratinized
•Appears as erythmatous areas
surrounded by reticular elements.
•Affects the gingiva also and gives a
bright red edematous pattern
involving the full width of attached
• Probably develop as a complication of atrophic
process and not necessarily Bullous lesions.
•Occurs more on the buccal mucosa
•A pseudo membrane covers the lesion
•Rarely observed form
•Bullae and vesicles range from few mmseveral cm.,short-lived and rupture into
•Seen in postero-inferior aspect of the buccal
•Striae to be seen here also.
stomatitis,SLE and DLE.
Erosive and Bullous-vesiculo-bullous lesions.
Annular-erythema circinata migrans
EROSIVE LICHEN PLANUS
Treat with topical/systemic
vitamin A for reversal of
An insidious chronic disease affecting any
part of the oral cavity & sometimes the
pharynx occasionally preceded by &/or
assoc with vesicle formation and always
assoc with juxtaepithelial inflammatory
reaction,followed by a fibro elastic change
of laminapropria with epithelial atrophy
leading to stiffness of oral mucosa and
causing trismus and inability to eat
ARECANUT CHEWING WITH
Collagen fibrils resistant to
MUSCLE FATIGUE AND DEGENERATION
FIBROSIS AND SCARRING OF THE MUSCLE
•Any age - 20 – 60 yrs predominantly
•Burning sensation of the oral cavity aggravated by
•Vesiculation, excessive salivation, ulceration,
pigmentation, recurrent stomatitis, defective
gustatory sensations and dryness of mouth.
•Gradual stiffening of oral mucosa after few yrs.
•Difficulty in swallowing when fibrosis extends
to pharynx and esophagus
•Referred pain in ears, deafness and nasal voice
localized,diffused or lace -like network.
•As disease progresses mucosa becomes stiff and
vertical fibrous bands appear.
In lip-circular bands appear. (Circum rima oris)
In severe involvement of the lip-lips become leathery,
difficult to avert
In palate-bands radiate from the pterygomandibular
raphe to the anterior faucial pillars.
Faucial pillars - thin and short.
•Tonsils- may be pressed between the faucial
•Soft palate -Mobility is restricted when is
bud like or hockey stick
•Tongue-devoid of papillae, stiff with
impaired protrusion in severe cases
•Floor of the mouth-blanched and leathery
•Petechiae seen in 1/5th of cases.
CLINICAL AND FUNCTIONAL STAGING
Haider et al 2000 BJOMS
•Stage 1-faucial bands only
•Stage 2-faucial and buccal bands
•Stage 3-faucial,buccal and labial bands
•A –mouth opening >20mm
•B-mouth opening 11-19 mm
•C-mouth opening < 10 mm
•Decreased serum iron
•Increased total Fe binding capacity
•Decreased total saturation of transferrin
•Decreased total serum iron
Elimination of the habit
Cases without bands-topical corticosteroids
Cases with bands-intra-lesional corticosteroids
Formulations and dosage
Dexamethasone – 2ml (1ml on each side surrounding
the bands)-biweekly for 10 weeks
Hydrocortisone – 1.25 ml once a week for 12 weeks
Dexamethasone – 2ml+hyalurinadase 1500
IU,biweekly for 10 weeks
Hydrocortisone – 1ml+ hyalurinadase 1500
IU,biweekly for 10 weeks
IS A PREMALIGNANT SQUAMOUS
CELL LESION DUE TO LONG TERM
EXPOSURE TO SOLAR RADIATION.
•Seen on skin,Vermillion border of the lip as a
crusted and Keratotic lesion.
•Labial mucosa exposed to the sun- white area of
atrophic epithelium develops underlying scarring of
lamina propria( referred to as Elastosis )
•Malignant transformation (10%)
Topical 5-fluoro uracil
Surgical lip shaving
Topical steroids in
between treatments to
control lip swelling
Occurs in 15-35 yrs old.
Highest in Blacks(USA),lowest in Indians
The buccal mucosa exhibiting a grayish- white
,slightly folded ,opalescent appearance with normal
softness and flexibility is termed leukodema.
This change temporarily eliminated by stretching the
mucosa,but re-establishes itself immediately.
Melanin pigmentation enhances opalescence
The line of keratinization usually found
on the non-keratinized buccal mucosa
parallel to the line of occlusion and
expanding to a triangular area in the
Ectopic presence of tubulo-acinar sebaceous glands in
Appears in 80-90 % of adult population.
Seen on Vermillion border, buccal mucosa,
occasionally on the palate , gingiva and the
No specific function/does not increase with
WHITE SPONGY NEVUS
Etiopathogenesis : Mutations in
Genes Coding For
Epihtelial Keratin Of Type K4 N K33.
M=f.Autosomal Dominant Disorder….
Site : Buccal Mucosa.
Extra Oral Sites : Oesophagus,anogenital Mucosa.
.Management: No Specific Treatment Required.
WHITE SPONGY NEVUS
ETIOLOGY: HEAVY CIGARETTE ,PIPE ,CIGAR SMOKING.
C/F:NUMEROUS ELEVATED PAPULES WITH RED PUNCTATED
CENTER…… INFLAMMED SALIVARY GLAND WITH ALTERED
METAPLASIA,MILD TO MODERATE INFLAMMTION.
MEDIAN RHOMBOID GLOSSITIS
NAME GIVEN BYSCHIERMER
GREEK WORD- Leucos
means white and plakia
It is a predominantly white lesion of the oral mucosa
that cannot be characterized as any other definable
lesion ,some oral Leukoplakia’s will transform into
AXELL.T. et al (1996)
Tobacco(chemical constituents and combustion
products such as tars and resins)
additional effect of heat from the
burning of tobacco
Irritation of oral mucosa producing
Three types :
Age – average 60 yrs(less than 20 also recorded)
Sex – M:F = 3:2
Site – although leukoplakia can be found in any
location,buccal mucosa,gingivae and Vermillion
border of the lip are involved.Lips,palate,retro
molar area ,floor of the mouth,tongue are less
•Homogenous refers to a localized lesion or an
extensive white patch that presents a relatively
consistent pattern throughout ,even though the
surface of the lesion may be described variously as
corrugated(ebbing tide),with a pattern of fine
Nodular leukoplakia refers to a mixed red and
white lesion with small Keratotic nodules are
scattered over an atrophic patch of mucosa
Verrucous leukoplakia is one in which the
surface is broken up by multiple papillary
projections that may also be heavily keratinized
producing a lesion that bears some resemblance
to the dorsum of the tongue.
SMEAR-to rule out candidal involvement
Toludine blue application.
SYPHILITIC WHITE PATCH
LEUKOPLAKIA INDUCED BY GALVANISM,TRAUMA,ETC.
PLAQUE TYPE LICHEN PLANUS
ATROPHIC LICHEN PLANUS
Over all : 3-6%
Type wise : Homogenous 0.5-1.7 %
Site wise : Floor of the mouth - highest
Stop the habit
Topical anti fungal for 2 weeks
Biopsy and topical Vit A application
Beta carotene 5000 IU/day(chemo
GUIDELINES FOR MANAGEMENT
Clinical observation without biopsy is dangerous
Response to hyperkeratotic leukoplakia is
unpredictable,so biopsy to be repeated every 6 –
12 months particularly if the lesion changes in
size or physical characteristics.
Adequate follow up,especially for
nodular,Verrucous forms and leukoplakia at the
floor of the mouth and tongue.
Surgical stripping with graft
Marked changes in the oral microbial flora
Broad spectrum antibiotics
Excessive use of anti microbial mouth rinses.
Xerostomia secondary to anticholinergic agents and
Chronic local irritants.
Administration of cortico steroids
(topical,oral,inhalation & systemic)
Radiation to head and neck
Age (infancy,pregnancy,old age)
Hospitalization age, debilitating diseases,antibiotics)
Superficial infection of the upper layer of the
epithelium,resulting in the formation of patchy white
Surrounding mucosa-may /may not be
reddened.Plaque removal ,by rubbing or scraping shows
Transient episodes of thrush may occur as
isolated prominences that disappear
spontaneously with minimum/no
Common neonates and children.
Typical lesion of infants-soft white or bluish
white,adherent patches on the oral mucosa at
times,extending to circum oral tissues.
Lesions are painless
Can be removed with tissue difficultly,leaving
raw bleeding surfaces.
In adultsLesions may evolve beneath dentures or any
other area of the oral cavity.
Inflammation,erythema and painful eroded
may more be more often associated with.
Entire oral mucosa may be involved.
Mild symptoms compared to other stomatitis’
Burning of mouth and throat precede in
antibiotic therapy predisposed.
CHRONIC PLAQUE TYPE
CHRONIC NODULAR TYPE
Flecks of milk
Flecks of food debris
Antacids remaining on the oral mucosa ,esp. in
Debilitated elderly patient ( intern’s thrush )
Includes antibiotic sore mouth.
Red pattern of raw atrophic mucosa persists with no
evidence of pseudomembranes.
Generalized depapillation of tongue.
Palate and buccal mucosa can be involved.
Pt develops symptoms of bad taste,oral burning,sore
throat during convalescent periods of illness,treated
with broad – spectrum antibiotics.
Raised lesions that vary from small,palpable,translucent areas
whitish areas to large dense opaque plaques which are hard and
rough to touch.
Homogenous/Speckled/Nodular areas which do not rub off.
3- 50 % of candida –hyperplastic.
Cream Apply to affected area.
Oral suspension, Apply after meals 4x/d, usually for 7
d, 100,000 U continue use for several days after post
Candid -B cream
•Traumatic : Irritation is the foremost etiology.
Inadequate,ill fitting dentures,
Chemical action of free monomer
Poor denture hygiene
Putrefaction of chemical food
Hypersensitivity to denture material
Nonspecific bacteria, candidal species
•Malnutrition: Alcoholism, DM (uncontrolled) Anemia's
Resistance to treatment
•Stomatitis with palatal inflammatory hyperplasia
Palatal mucosa – velvety or may resemble
an over ripe berry and bleed on slight
Pain and burning
Intensely reddened ,glistening and slightly
Any inflammatory lesion of
the corner of the mouth.
Intensely red,fissured,eroded or ulcerated
Generally accompanied by symptoms of
soreness,tenderness,burning or frank pain.
•Intensely red in the muco-cutaneous
junction surrounding the skin.
•Fissures and superficial erosion on an
•Ulceration coated with Greyish-white
or yellow membrane or exudate.
Loss of intermaxillary distance
Closure of bite,acceleration
of transverse folds of skin at
the angle of the mouth.
Saliva drools out at the corners
Fluids deposited leaves accentuated folds.
Drying of saliva and formation of
irritating end- products
Traumatic type :
•Smear from the lesion
•Swab : cotton dipped swab
•Candida agglutination,precipitation immunoflorescence
TLC,DC,Folate,Vit B 12,Serum Ferritin
Topical antifungal : Clotrimazole( Azoles )
:200 mg x 7 days
: 50 mg O.D x 10 days
: 100 – 200 mg/day x 2
50 – 150 mg/kg/day x
quad/day(divided doses )